Decaf, OK? Part 3

Isn’t it amazing what respect can do? This is what I mean when I say, “When is the last time you got angry at someone treating you with respect?” You don’t. And, from my experience, this can extend even to the psychotic brain. But respect alone is not enough to re-calibrate a brain that has this degree of perceptual distortion. So I started Dan on medication.

Decaf, OK? Part 3

He was my first patient on Clozaril®, a new antipsychotic that had just come out in the early 1990’s. I was a second year resident doing one of my inpatient rotations, and Dan was one of my patient/teachers. By the time of the chair incident, I had known him for a week, tremendously paranoid and just wanting to “go home.” He was on a court order to take medication, judged too impaired by his psychiatric condition to make his own decisions about his treatment.

Clozaril® had just been added to the treatment plan, but he had not started. We spoke about it over coffee, about the need for weekly blood draws to check his white blood cell count, about how fast we could go up on the medicine, about how it was new and worked differently but may not work at all, about how grateful I was that he put down the chair and did not need to be restrained or given injections.

Dan nodded gently as he sipped his decaf with cream. He was still paranoid, but being treated with respect and dignity he would calm. Not until more than a decade later did I recognize that the style of care I was developing as a resident had a calming effect on patients, (and staff). By treating them with dignity. By seeing them at their Imax. (See the Imax section on my website.) By letting them know they are valuable and that I have a true interest in who they are and why they do what they do, as a person not a chart nor diagnosis, these people at their time of greatest need and vulnerability recognized I was just trying to help and rarely would become enraged.

Even in the throes of psychosis a patient can usually recognize when they are not in danger, although they can perceive danger where none exists. They still can access that part of their brain interested in what other people think or feel about them. They have to: very often they are in survival mode. Understanding the world around them takes on vital importance. And even though in paranoia and delusions these perceptions are distorted, there seems to be an island of reality when a psychotic person sees you as treating them with respect. Perhaps it is a bastion of comfort that in their world of imminent danger they have found someone who is willing to listen, as a safe haven. It was through respect that I was able to calm Dan down. He did not perceive me as seeing him as a threat, nor did he see me as threatening.

For Dan, I am convinced that if I had come in to the ward and demanded he put down the chair, or addressed it at all, the nurse would have been injured and Dan eventually restrained. By my doing something non-threatening, even perhaps outrageous and off-topic, Dan was able to withdraw from his aggression and paranoia, and put down the chair.

So we sat together and prepared to start yet another new medicine.He was my first patient on Clozaril®, a new antipsychotic that had just come out in the early 1990’s. I was a second year resident doing one of my inpatient rotations, and Dan was one of my patient/teachers. By the time of the chair incident, I had known him for a week, tremendously paranoid and just wanting to “go home.” He was on a court order to take medication, judged too impaired by his psychiatric condition to make his own decisions about his treatment.

So we sat together and prepared to start yet another new medicine.

WHAT DO YOU THINK HAPPENS NEXT? AS DAN WITHDRAWS FROM HIS AGGRESSION AND PARANOIA, WHAT DO YOU THINK I FOUND UNDERNEATH?

I’ll tell you what happened after the next ten comments. ~Dr. Joe

lydsnow

This story reminds me of a conversation with my almost 17 year old son. I asked him what he would do if his son (my friend had sent me a message about a son in trouble) was unreachable and in trouble. He said, “I would talk to him like a man, like dad does with me!” I asked, “What do you mean?” And he said, “When dad really wants to communicate, he talks to me with respect, like I’m a man. And then I let him know what’s going on!” I think my husband is a brilliant father, but also he just cares and has the patience to listen!

coneflower

Hmmmm……… What happens next? He developed agranulocytosis and died? No, somehow I don’t think that is how this story ends. However, it is difficult to imagine how clearly one can see what lies beneath Dan’s aggression and paranoia, once he has been dosed with a heavy-duty anti-psychotic. But, I will admit that I don’t really know what these drugs do.

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